1285643544 NPI number — DR. FREDERICK JARL THYSELL MD

Table of content: DR. FREDERICK JARL THYSELL MD (NPI 1285643544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285643544 NPI number — DR. FREDERICK JARL THYSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THYSELL
Provider First Name:
FREDERICK
Provider Middle Name:
JARL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285643544
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1416 JESICA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SELAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98942-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-829-3861
Provider Business Mailing Address Fax Number:
509-469-1905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2807 W WASHINGTON AVE
Provider Second Line Business Practice Location Address:
STE 117
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98903-1367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-469-1903
Provider Business Practice Location Address Fax Number:
509-469-1905
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  MD00024540 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8120578 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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